Natalie A. Mariano, MD
Requests for Single Reprints: Natalie A. Mariano, MD, 15 Simpson Lane, Falmouth, MA 02540; e-mail, Natshell@aol.com.
Mariano N.; Valentine. Ann Intern Med. 2003;138:354-355. doi: 10.7326/0003-4819-138-4-200302180-00019
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Published: Ann Intern Med. 2003;138(4):354-355.
My grandmother died the night before her 50th wedding anniversary. My father was with her, having tea at her kitchen table, when she grabbed her chest and fell to the floor. The doctor said it was a heart attack. My father said she died of a broken heart because she had just heard some bad news about her brother. Our next-door neighbor had made a beautiful red velvet dress for me to wear to her anniversary party. I never got a chance to wear it. I was 11 years old and didn't know what a heart attack was. I thought a heart was the color of red velvet and the shape of a valentine.
Years later, I learned what a heart really looks like. I was a first-year medical student in anatomy class, dissecting the preserved body of an old man. I had looked forward to seeing a human heart seated in its throne of the chest, but when we opened the chest cavity and found the sacred organ, I felt like a child the day after Christmas. The heart was not the bright red color of the velvet dress my neighbor had made for my grandmother's party. Nor was it in the shape of a valentine. It was the color of wet red tissue paper, and in the shape of a birthday balloon that has lost most of its air.
A physician listens to the sounds a living heart makes when it beats in the chest, pumping lifeblood to every organ in the body. The sounds are crisp, rhythmic staccatos of heart valves slamming shut as the muscular pump squeezes blood through its chambers and into the circulation. Like a teenager listening to rock music on her earphones, I listen to the music of the heart through the earpieces of my stethoscope. The healthy, pounding hearts of youth play loudly and rhythmically, while the frail, antique instruments of the elderly play soulful, discordant melodies with erratic rhythms.
Mrs. MacGregor lies in her bed at the nursing home. As the blood flows through her weakened heart valves, it leaks backward with each beat, filling her lungs with fluid and making it difficult for her to breathe. I remember her picture in The Ledger that was taken when her square dancing group gave her a surprise party on her 90th birthday. She was proud of her age and her raven black hair, peppered with enough gray to make sure that no one thought she dyed it. She danced with children at elementary schools and with the old at nursing homes, thankful for her health and her two replaced hips.
Now she is 96. She stopped square dancing 2 years ago when she developed heart failure. Her face is faceted with wrinkles that weren't there 4 years ago, and her hair is now more silver than black. But when she sees me at her bedside, her wrinkles explode into a smile that brightens her eyes and colors her cheeks. She takes my hand in hers, and we talk. Before leaving, I listen to her failing heart and moist lungs, and wonder how much longer her music will play. Saying goodbye, she thanks me for coming and whispers, “Tell your mother I'm awfully glad she had you.” These words come straight from her heart.
A heart writes mysterious stories, and we record them on cardiograms. Sharp, black lines etched across fine gray graph paper trace the electrical current that surges through heart muscle. Each little blip and spike narrates a detail of a story. It may describe the pain of an old heart that doesn't get enough oxygen when asked to pump more blood to legs that are trying to walk. It may describe the palpitations of a young heart that has just fallen in love.
Anne comes to see me for her annual check-up. She is more tired than she used to be, but expects it's part of being 46. Her face shows some wear from caring for her two young daughters while running her own business. Her laughter muffles the tension in her voice as she describes the stress of her day. I examine her and tell her she's healthy, but I encourage her to cut back on her workload. We enjoy our visit and the chance to catch up on the details of her life. We part, thinking we'll meet again in a year.
Two weeks later, I am surprised to find Anne's name listed on the census sheet from the intensive care unit. Reading her diagnosis, I assume there has been a mistake. I run to the intensive care unit and find her in bed, attached to a monitor, with an IV in her arm and an oxygen cannula under her nose. Her cardiogram narrates a chapter that had not been written the week before. Anne has survived a heart attack.
She is transferred to Boston for cardiac catheterization. Cardiologists find a blockage of one of the major arteries supplying blood to her ventricle. They open up the blockage with angioplasty and then reassure her that her heart is healthy and that she will do well.
Anne is back home now. Her pulse and blood pressure are normal, and her heart sounds are clear and crisp. Her cardiogram only hints at the details of the recent events in her life. Outwardly, she bears no sign of the life-threatening event that happened one night while she was carrying laundry from the basement. But now she makes sure that her daughters know how to dial 911 and that her husband takes his cell phone whenever he leaves the house. Each time Anne has indigestion or a muscle spasm in her chest, she worries that it might be her heart. She follows my instructions to call me, and we worry together. Someday we'll be more confident that her heart is okay, but now we remember how her life changed in the space of a single heartbeat.
I'm called to the nursing home to see an elderly man who is dying. The man thrashes about in bed and struggles to breathe. His heart is too weak to pump blood forward, and he is drowning in fluid that is backed up in his lungs. Ashen and soaked in sweat, he looks wildly around the room for help. When I approach, he stops struggling and rests his eyes on me. The muscles of his face relax, and he almost smiles.
“Hey, Doc,” he calls to me, the way he has for years. I go to his bedside and take his hand.
“Relax, we're going to make you feel much better,” I assure him, not knowing whether we can. Telling the nurse to get some morphine, I sit down beside him and gently rub his hand. His long fingers are icy and white. I look down to see my own hand, usually frigid enough to make patients squeal at its chill, now bright red and glowing with heat. I set my mind on sending the warmth of my body into his, through the tips of our fingers.
The nurse returns with the morphine and injects a small dose into his vein. Within minutes his exhausted eyes shut, and he lies back in his bed. The rattling of his rapid breathing disappears, and a slow ebb and flow of air in and out of his mouth quietly fills the room. I sit silently beside him, keeping vigil, as the nurse goes back to her duties. His breathing stops for a few seconds at a time, and then starts again in rapid, shallow pants. Each time I think he has died, he inhales once more and keeps me bound to his bedside. Finally, his breathing stops.
I lay my stethoscope on his chest and listen for the sounds of his heart, but hear only silence. I kiss his ashen forehead and squeeze his cool hand. Hesitant to leave his side, I walk back to the desk to call his daughter. Telling her that her father has died, I feel my heart rise in my throat and hear the echo of its beating in my ears. She thanks me for the call, her voice filled with sadness.
I pick up a black pen to complete a death certificate and write “heart failure” on the line marked “Cause of Death.” Glancing at my watch to note the time of death, I realize I have just enough time to get to the card store before it closes. If I mail a card tonight my mother will have it for Valentine's Day.
Natalie A. Mariano, MD
Falmouth, MA 02540
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